National Institute on Alcohol Abuse and Alcoholism No.

46 December
1999

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Are Women More Vulnerable to Alcohol's Effects?

Women appear to be more vulnerable than men to many adverse

consequences of alcohol use. Women achieve higher concentrations
of alcohol in the blood and become more impaired than men after
drinking equivalent amounts of alcohol. Research also suggests that
women are more susceptible than men to alcohol-related organ
damage and to trauma resulting from traffic crashes and
interpersonal violence. This Alcohol Alert examines gender
differences in alcohol's effects and considers some factors that may
place women at risk for alcohol-related problems.

Prevalence of Women's Drinking

Household surveys indicate that alcohol use is more prevalent among

men than women in the United States (1,2). In one survey, 34 percent
of women reported consuming at least 12 standard drinks1 during the
previous year compared with 56 percent of men (1). Among drinkers
surveyed, 10 percent of women and 22 percent of men consumed
two or more drinks per day on average (1). Men are also more likely
than women to become alcohol dependent (3).2

Women¹s drinking is most common between ages 26 and 34 and

among women who are divorced or separated (2). Binge drinking
(i.e., consumption of five or more drinks per occasion on 5 or more
days in the past month) is most common among women ages 18 to
25 (2). Among racial groups, women's drinking is more prevalent
among whites, although black women are more likely to drink heavily
(1).
Metabolism

Women absorb and metabolize alcohol differently than men. In

general, women have less body water than men of similar body
weight, so that women achieve higher concentrations of alcohol in the
blood after drinking equivalent amounts of alcohol (5,6). In addition,
women appear to eliminate alcohol from the blood faster than men.
This finding may be explained by women¹s higher liver volume per
unit lean body mass (7,8), because alcohol is metabolized almost
entirely in the liver (9).

Consequences of Alcohol Use

Research suggests that women are more vulnerable than men to

alcohol-related organ damage, trauma, and legal and interpersonal
difficulties.

Liver Damage. Compared with men, women develop alcohol-

induced liver disease over a shorter period of time and after
consuming less alcohol (10,11). In addition, women are more likely
than men to develop alcoholic hepatitis and to die from cirrhosis (12).
Animal research suggests that women¹s increased risk for liver
damage may be linked to physiological effects of the female
reproductive hormone estrogen (13).

Brain Damage. Views of the brain obtained by magnetic resonance

imaging (MRI) suggest that women may be more vulnerable than
men to alcohol-induced brain damage. Using MRI, researchers found
that a brain region involved in coordinating multiple brain functions
was significantly smaller among alcoholic women compared with both
nonalcoholic women and alcoholic men. These differences remained
significant after measurements were adjusted for head size (14).
Conversely, a study measuring metabolic energy utilization in
selected brain regions found a significant difference between
alcoholic and nonalcoholic men but no significant difference between
alcoholic and nonalcoholic women (15). These results are not
consistent with a greater vulnerability to alcoholic brain damage in
women. However, the female alcoholics reported less severe alcohol
use compared with the male alcoholics studied (15).

Heart Disease. Men and women who consume one or two alcoholic
drinks per day have a lower death rate from coronary heart disease
(e.g., heart attacks) than do heavier drinkers and abstainers, as
discussed in Alcohol Alert No. 45, "Alcohol and Coronary Heart
Disease" (16). Among heavier drinkers, research shows similar rates
of alcohol-associated heart muscle disease (i.e., cardiomyopathy) for
both men and women, despite women's 60 percent lower lifetime
alcohol use (17).

Breast Cancer. Many studies report that moderate to heavy alcohol

consumption increases the risk for breast cancer (18), although one
recent study found no increased breast cancer risk associated with
consumption of up to one drink per day, the maximum drinking level
reported by most women (19).

Violent Victimization. A survey of female college students found a

significant relationship between the amount of alcohol the women
reported drinking each week and their experiences of sexual
victimization (20). Another study found that female high school
students who used alcohol in the past year were more likely than
nondrinking students to be the victims of dating violence (e.g.,
shoving, kicking, or punching) (21).

A history of heavy premarital drinking by both partners has been

found to predict first-year aggression among newlyweds (22). In
some studies, problem drinking by wives has been linked to husband-
to-wife aggression regardless of the husbands¹ drinking levels (23).

Traffic Crashes. Although women are less likely than men to drive
after drinking (1,24) and to be involved in fatal alcohol-related
crashes (25), women have a higher relative risk of driver fatality than
men at similar blood alcohol concentrations (26). Laboratory studies
of the effects of alcohol on responding to visual cues and other tasks
suggest that there may be gender differences in how alcohol affects
the performance of driving tasks (27).
Women’s lower rates of drinking and driving may be attributed to their
lower tendency toward risk taking compared with men (28,29).
Women are also less likely to view drinking and driving as acceptable
behavior. In a 1990 national household survey, 17 percent of women,
compared with 27 percent of men, agreed that it was acceptable for a
person to drink one or two drinks before driving (30). Nevertheless,
the proportion of female drivers involved in fatal crashes is
increasing. In 1996, 16 percent of all drivers involved in alcohol-
related fatal crashes were women, compared with 13 percent in 1986
and 12 percent in 1980 (25).

Risk Factors for Women's Alcohol Use

Factors that may increase women¹s risk for alcohol abuse or

dependence include genetic influences, early initiation of drinking,
and victimization.

Genetic Factors. The relative contribution of genetic factors to

women¹s risk for alcoholism has been debated. A survey of 2,163
female twins revealed greater similarity between identical twins
compared with fraternal twins on measures of alcohol consumption
(31). Similar studies including more than 12,000 twin pairs from the
general population have confirmed that among both male and female
twin pairs, identical twins are more likely than fraternal twins to have
similar rates of alcohol dependence, alcohol abuse, and heavy
alcohol consumption (32,33).

Studies of women who had been adopted at birth have shown a

significant association between alcoholism in adoptees and their
biological parents (34). In addition, antisocial personality (e.g.,
aggressiveness) in biological parents may predict alcoholism in both
male and female adoptees (35). However, potential interactions
between genetic and environmental influences require further study.

Using laboratory animals, researchers are currently attempting to

identify gender-specific genetic factors whose interactions might
contribute to differential sensitivity to alcohol¹s effects (36).
Age of Initiating Drinking. Results of a large nationwide survey
show that more than 40 percent of persons who initiated drinking
before age 15 were diagnosed as alcohol dependent at some point in
their lives (37). Rates of lifetime dependence declined to
approximately 10 percent among those who began drinking at age 20
or older. The annual rate of this decline was similar for both genders
(37). Although in the past women generally started drinking at later
ages than men, more recent survey data show that this difference
has nearly disappeared (2).

Victimization. Using data collected in a large general population

survey, Wilsnack and colleagues (38) found that women who
reported being sexually abused in childhood were more likely than
other women to have experienced alcohol-related problems (e.g.,
family discord or household accidents) and to have one or more
symptoms of alcohol dependence. Another study found that women
in alcoholism treatment were significantly more likely to report
childhood sexual abuse and father-to-daughter verbal aggression or
physical violence compared with women in the general population
(39).

Widom and colleagues (40) reached a different conclusion from that

of Miller and colleagues. Instead of relying on women's recall of their
pasts, Widom and colleagues consulted court records to identify
cases of childhood physical or sexual abuse. These researchers
found that for women, a history of childhood neglect, but not abuse,
significantly predicted the number of alcohol-related symptoms
experienced, independent of parental alcohol or other drug (AOD)
problems, childhood poverty, race, and age.

Physical abuse during adulthood has also been associated with

women's alcohol use and related problems. One study found that
significantly more women undergoing alcoholism treatment
experienced severe partner violence (e.g., kicking, punching, or
threatening with a weapon) compared with other women in the
community. In addition, among women in the community group, those
with AOD-related problems reported significantly higher rates of
severe partner violence than women without such problems. Although
the findings indicate that partner violence and AOD problems co-
occur among women, the data do not indicate whether the
association is causal (41).

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Are Women More Vulnerable to Alcohol¹s Effects?‹A

Commentary by NIAAA Director Enoch Gordis, M.D.

As can be seen by the varied types of information reported on in this

Alcohol Alert, the alcohol research field has begun to recognize the
importance of understanding gender differences in how alcohol is
used, in the consequences of alcohol use, and in the development of
alcohol dependence. For example, where women and men drink at
the same rate, women continue to be at higher risk than are men for
certain serious medical consequences of alcohol use, including liver,
brain, and heart damage. We know that some of this risk is due to
gender differences in metabolism; it also could quite possibly be due
to gender-related differences in brain chemistry, in genetic risk
factors, or to entirely different factors that are currently unknown. The
more science can tell us about gender-related aspects of alcohol-
related problems‹not only what they are but why‹the better job we will
be able to do to prevent and treat those problems in all populations.

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References

(1) NIAAA. Drinking in the United States: Main Findings From the
1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES).
U.S. Alcohol Epidemiologic Data Reference Manual. Vol. 6. 1st ed.
Bethesda, MD: The Institute, 1998. (2) Su, S.S.; Larison, C.;
Ghadialy, R.; et al. Substance Use Among Women in the United
States. SAMHSA Analytic Series A-3. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 1997. (3) Grant,
B.F. Prevalence and correlates of alcohol use and DSM-IV alcohol
dependence in the United States: Results of the National Longitudinal
Alcohol Epidemiologic Survey. J Stud Alcohol 58(5):464-473, 1997.
(4) American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition. Washington, DC: the
Association, 1994. (5) Frezza, M.; Di Padova, C.; Pozzato, G.; et al.
High blood alcohol levels in women: The role of decreased gastric
alcohol dehydrogenase activity and first-pass metabolism. N Engl J
Med 322(2):95-99, 1990. (6) Taylor, J.L.; Dolhert, N.; Friedman, L.;
et al. Alcohol elimination and simulator performance of male and
female aviators: A preliminary report. Aviat Space Environ Med
67(5):407-413, 1996. (7) Li, T.K.; Beard, J.D.; Orr, W.E.; et al.
Gender and ethnic differences in alcohol metabolism. Alcohol Clin
Exp Res 22(3):771-772, 1998. (8) Kwo, P.Y.; Ramchandani, V.A.;
O¹Connor, S.; et al. Gender differences in alcohol metabolism:
Relationship to liver volume and effect of adjusting for body mass.
Gastroenterology 115(6):1552-1557, 1998. (9) Levitt, M.D.; Li, R.;
DeMaster, E.G.; et al. Use of measurements of ethanol absorption
from stomach and intestine to assess human ethanol metabolism. Am
J Physiol Gastrointest Liver Physiol 3 (4):G951-G957, 1997. (10)
Tuyns, A.J., and Pequignot, G. Greater risk of ascitic cirrhosis in
females in relation to alcohol consumption. Int J Epidemiol 13(1):53-
57, 1984. (11) Gavaler, J.S., and Arria, A.M. Increased susceptibility
of women to alcoholic liver disease: Artifactual or real? In: Hall, P.,
ed. Alcoholic Liver Disease: Pathology and Pathogenesis. 2d ed.
London, UK: Edward Arnold, 1995. pp. 123-133. (12) Hall, P.M.
Factors influencing individual susceptibility to alcoholic liver disease.
In: Hall, P.M., ed., Alcoholic Liver Disease: Pathology and
Pathogenesis. 2d. ed. London, UK: Edward Arnold, 1995. pp. 299-
316. (13) Ikejima, K.; Enomoto, N.; Iimuro, Y.; et al. Estrogen
increases sensitivity of kupffer cells to endotoxin. Alcohol Clin Exp
Res 22(3):768-769, 1998. (14) Hommer, D.; Momenan, R.; Rawlings,
R.; et al. Decreased corpus callosum size among alcoholic women.
Arch Neurol 53(4):359-363, 1996. (15) Wang, G.J.; Volkow, N.D.;
Fowler, J.S.; et al. Regional cerebral metabolism in female alcoholics
of moderate severity does not differ from that of controls. Alcohol Clin
Exp Res 22(8):1850-1854, 1998. (16) NIAAA. Alcohol Alert No. 45:
Alcohol and Coronary Heart Disease. Rockville, MD: the Institute,
1999. (17) Urbano-Marquez, A.; Estruch, R.; Fernández-Solá, J.; et
al. The greater risk of alcoholic cardiomyopathy and myopathy in
women compared with men. JAMA 274(2):149-154, 1995. (18)
Smith-Warner, S.A.; Spiegelman, D.; Yaun, S.S.; et al. Alcohol and
breast cancer in women: A pooled analysis of cohort studies. JAMA
279(7):535-540, 1998. (19) Zhang, Y.; Kreger, B.E.; Dorgan, J.F.; et
al. Alcohol consumption and risk of breast cancer: The Framingham
Study revisited. Am J Epidemiol 149(2):93-101, 1999. (20) Gross,
W.C., and Billingham, R.E. Alcohol consumption and sexual
victimization among college women. Psychol Rep 82(1):80-82, 1998.
(21) Malik, S.; Sorenson, S.B.; and Aneshensel, C.S. Community
and dating violence among adolescents: Perpetration and
victimization. J Adolesc Health 21(5):291-302, 1997. (22) Leonard,
K.E., and Roberts, L.J. Marital aggression, quality, and stability in the
first year of marriage: Findings from the Buffalo Newlywed Study. In:
Bradbury, T.N., ed. The Developmental Course of Marital
Dysfunction. Cambridge, UK: Cambridge University Press, 1998. pp.
44-73. (23) Leonard, K.E., and Senchak, M. Alcohol and premarital
aggression among newlywed couples. J Stud Alcohol/Suppl 11:96-
108, 1993. (24) Kann, L.; Kinchen, S.A.; Williams, B.I.; et al. Youth
Risk Behavior Surveillance: United States, 1997. MMWR 47(SS-3):1-
89, 1998. (25) Yi, H.; Stinson, F.S.; Williams, G.D.; et al. Trends in
Alcohol-Related Fatal Traffic Crashes, United States, 1977-96.
Surveillance Report No. 46. Bethesda, MD: NIAAA, 1998. (26) Zador,
P.L. Alcohol-related relative risk of fatal driver injuries in relation to
driver age and sex. J Stud Alcohol 52(4):302-310, 1991. (27) Waller,
P.F., and Blow, F.C. Women, alcohol, and driving. In: Galanter, M.,
ed. Recent Developments in Alcoholism. Vol. 12. New York: Plenum
Press, 1995. pp. 103-123. (28) Wells-Parker, E.; Popkin, C.L.; and
Ashley, M. Drinking and driving among women: Gender trends,
gender differences. In: Howard, J.M.; Martin, S.E.; Mail, P.D.; et al.,
eds. Women and Alcohol: Issues for Prevention Research. NIAAA
Research Monograph No. 32. Bethesda, MD: NIAAA, 1996. (29)
Arnett, J.J.; Offer, D.; and Fine, M.A. Reckless driving in
adolescence: ŒState¹ and Œtrait¹ factors. Accid Anal Prev 29(1):57-
63, 1997. (30) Greenfield, T.K., and Room, R. Situational norms for
drinking and drunkenness: Trends in the US adult population, 1979-
1990. Addiction 92(1):33-47, 1997. (31) Prescott, C.A., and Kendler,
K.S. Longitudinal stability and change in alcohol consumption among
female twins: Contributions of genetics. Development
Psychopathology 8(4):849-866, 1996. (32) Kendler, K.S., and
Prescott, C.A. Population-based twin study of alcohol abuse and
dependence: Modeling gender differences. Am J Med Genet
74(6):574, 1997. (33) Prescott, C.A.; Aggen, S.H.; and Kendler, K.S.
Sex differences in the sources of genetic liability to alcohol abuse and
dependence in a population-based sample of U.S. twins. Alcohol Clin
Exp Res 23(7):1136-1144, 1999. (34) Bohman, M.; Sigvardsson, S.;
and Cloninger, C.R. Maternal inheritance of alcohol abuse: Cross-
fostering analysis of adopted women. Arch Gen Psychiatry 38(9):965-
969, 1981. (35) Cadoret, R.J.; Yates, W.R.; Troughton, E.; et al. An
adoption study of drug abuse/dependency in females. Compr
Psychiatry 37(2):88-94, 1996. (36) Fernandez, J.R.; Vogler, G.;
Tarantino, L.M.; et al. Sex-specific QTL influences in alcohol-related
phenotypes: Analysis of an F2 population. Behav Genet 27(6):589,
1997. (37) Grant, B.F., and Dawson, D.A. Age at onset of alcohol
use and its association with DSM-IV alcohol abuse and dependence:
Results from the National Longitudinal Alcohol Epidemiologic Survey.
J Sub Abuse 9:103-110, 1997. (38) Wilsnack, S.C.; Vogeltanz, N.D.;
Klassen, A.D.; et al. Childhood sexual abuse and women's substance
abuse: National survey findings. J Stud Alcohol 58(3):264-271, 1997.
(39) Miller, B.A.; Downs, W.R.; and Testa, M. Interrelationships
between victimization experiences and women's alcohol use. J Stud
Alcohol/Suppl 11:109-117, 1993. (40) Widom, C.S.; Ireland, T.; and
Glynn, P.J. Alcohol abuse in abuse and neglected children followed-
up: Are they at increased risk? J Stud Alcohol 56(2):207-217, 1995.
(41) Miller, B.A. Partner violence experiences and women's drug
use: Exploring the connections. In: Wetherington, C.L., and Roman,
A.B., eds. Drug Addiction Research and the Health of Women.
Rockville, MD: National Institute on Drug Abuse, 1998. pp. 407-416.

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1A standard drink is 12 grams of pure alcohol, which is equivalent to

12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits.

2Alcohol dependence was defined according to the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition (4).

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